Comparison of Cancer Detection Between Transrectal and Transperineal Prostate Biopsy in an Active Surveillance Cohort

Transperineal (TP) prostate biopsy is increasingly favored over the transrectal (TR) approach because of a lower risk of infection, but comparative data on cancer detection remain limited. We analyzed a large institutional cohort to compare detection rates and disease location between the TP and TR approaches.

We included all men on active surveillance undergoing prostate biopsy at Memorial Sloan Kettering Cancer Center during the 26-mo transition from TR to TP. Data included demographics, biopsy method, histopathology, and magnetic resonance imaging (MRI) findings. The primary outcome was detection of high-grade cancer (Gleason grade group ≥2). Multivariable logistic regression was adjusted for clinical and imaging variables. Clustered standard errors were used to account for repeat biopsies.

We identified 1387 biopsies performed in 1304 patients from January 2020 to February 2023. Among all biopsies, 522 (38%) contained high-grade cancer and 602 (43%) contained grade group 1 disease. The empirical rate of high-grade cancer detection was 39% with TP versus 37% with TR biopsy (adjusted odds ratio 0.86, 95% confidence interval 0.66-1.10; p = 0.2). TP biopsy had a higher yield for high-grade anterior disease in comparison to TR biopsy (21% vs 9%; p < 0.001) but a lower yield for high-grade posterior disease (28% vs 34%; p = 0.044). Stratification by Prostate Imaging-Reporting and Data System score on MRI revealed consistent detection patterns across biopsy approaches when assessing disease location.

We found no significant difference in the overall detection rate for high-grade cancer between the TR and TP approaches, but there was some evidence of differences by tumor location, with TP biopsy better in sampling anterior tumors, and TR biopsy favoring posterior detection. These findings support the need for further studies, including randomized trials incorporating MRI and detailed location data, to clarify differences between the biopsy approaches in detection rates for different anatomic locations.